Preventing FallsA serious matter: One in four falls in the elderly proves fatal.

by Ralph K. Campbell, M.D.

(OMNS Oct 23 2018) Being a physician doesn't qualify me as an expert on falling. But because I am 91 years old, I have mighty good motivation to keep learning. In my experience, many geriatrists (specialists in the problems of older people) seem to lack the curiosity needed to listen to, and learn from, their patient's questions. Curiosity is motivated by a desire to really know the "whats" and "whys" of the changes that come with age and also by the desire to hear the patient's story. They can't get into these topics because, under the present medical care system, they don't have enough time. But common sense dictates that they need to discuss the basis of these problems before just prescribing pharmaceutical relief.

Aging: mental and muscular

If one looks around, it is easy to observe that aging is an individual thing, many times without a direct relationship to chronological age. Mental stress is a big factor in developing what we call aging. When we get worse in associating names with faces, this might foretell a need to think about the gradual decline in physical and mental functions. We say, "He is losing his grip"; yes, in muscles but also in ability and often in attitude. It is easy to observe problems that derive from diminishing sex hormone levels: hot flashes in women and some rearrangement of body fat around the waist, and an overly-emphasized diminished libido in men. The less obvious, but more significant, effect in men is diminished muscle strength and muscle wasting when testosterone levels fall. A similar effect of muscle weakening with age exists in women.[1] But we know that using muscles is an excellent way to slow the wasting process.

Quads and squats

What does this have to do with falling? When you begin to fall forward, you quickly and instinctively thrust a foot out in front in order to catch yourself. If your quadriceps (the big thigh muscle) is weak, you may not be able to catch yourself. I feel jealous watching a NFL running back who leaps high to complete a forward somersault---he can't put his hands down, because he has to hang on to the ball--and lands squarely on the back of his neck and upper thoracic spine, then pops up on his feet as if it never happened. So don't try this in your home. But maybe do some squats every day. A five- or ten-pound weight in each hand makes this exercise even better.

Nutrients help

It has been shown that, with age, one has a diminished ability to make creatinine, a precursor of ATP, responsible for muscle strength. Fortunately there is creatinine in supplement form; so it can be used in conjunction with the "use it or lose it" principle. [2-5] Other supplements of essential nutrients may also help, including the B vitamins, vitamin D, and omega-3 fatty acids. Excellent nutrition including adequate amounts of vitamins and essential nutrients is known to be important for maintaining weight, muscle mass, and cardiovascular health. [6-8] Vitamins C and E are necessary, especially in older people, to maintain skin, joints, muscles, blood vessels, and many organs including nerves and the brain. [9] And to get the most improvement with exercise, it's important to eat enough protein.

"Postural sway is linked to increased risk of falls, and sway was more prevalent in those with serum 25(OH)D [vitamin D] concentrations below 30 nmol/L."

Muscle sense

Proprioception is a kind of muscle sense through nerve endings in muscles that are stimulated by contraction. With age, we gradually lose the sense of proprioception. We have difficulty going down stairs while carrying a load that obscures our vision as we wonder "where did that next step go," or "just where is my foot?" In our youth, proprioception automatically did the "looking" for us. Just walking on an uneven surface now can cause confusion. A substitute for healthy proprioception is a must for those experiencing aging, and that is having - and using - a hand rail next to steps. With one hand on a railing, one can feel better oriented in space. The ease of negotiating steps may vary. There will be times in which we are only comfortable when taking baby steps. So be it. After all, we are in our second childhood.

The eyes have it

Cataract formation (opacity of the lens of the eye) is common in older folks. We have enjoyed eye-dominance -- the brain's reliance on seeing the world around us -- all our lives. When we change our focus from one object to the other, we almost instantaneously zero in with our dominant eye as the other eye follows. The greater the difference in visual acuity between the eyes, the longer the lag time that provides a moment of "where am I?" Proper depth perception depends on eyes, with similar acuity, working together. When vision is quite poor in one eye, we lose stereoscopic vision or depth perception. Again, an irregular surface can present a problem, as one might not detect the irregularity in time to avoid it. Adequate doses of essential nutrients from an excellent diet and supplements, including the B vitamins, and vitamins C, D, and E, omega-3 fatty acids, zinc, and magnesium, are essential to maintain health of the eyes as we age. [10]

One at a time

Nobody performs their best with multitasking. Older folks are particularly affected. The old adage of "don't try to think and chew gum at the same time" has some merit. Just put your full attention on the task at hand. If you are smart enough to operate a smart phone, don't do it while going downstairs, walking, or doing anything else. Even smart kids are having trouble with this.

Ears, brain and balance

An easy test to demonstrate that balance "ain't what it used to be" is to try standing on just one leg. Since you might not do too well, try this in a place where you have something to grab onto if you start to fall. This deterioration of balance is made worse by a sudden change in position, probably due to deterioration of function of the semi-circular canals of the inner ear. These act like gyroscopes to tell you just where you are in space---something automatic that we often don't think about. There may be a connection between hearing loss and the workings of the inner ear. So if you have hearing loss, it might be better to be checked out by an ENT doctor, who can also evaluate inner ear function, before being fitted with a hearing aid.

Blood circulation

Arising from a sleeping position too quickly may cause hypotension or even fainting. There are sensors in the carotid arteries (in the neck) that are designed to immediately kick in to avoid even momentary inadequate blood supply to the brain. However, these sensors don't function as well in the elderly, and often the carotid arteries are not as open as they used to be. So make that position change more slowly. Take stock of what you safely can do and what you can't. If you feel hesitant to get on a ladder, don't.

Maybe you think like I do: I don't as much fear falling as I do landing. I might slip on the ice. But I would much rather fall forward and risk breaking a wrist, than backwards and hit my head which can produce a concussion or, more subtly, cause bleeding entrapped by the covering of the brain (cephalohematoma) which may amount to real neurological trouble soon after. This problem develops much more readily in those on a daily aspirin regimen. The rigid, boney skull, of course, stops suddenly as it hits the hard surface, but the brain inside moves abruptly, which might cause blood vessels to tear. The bleeding may rapidly come to a stop unless enhanced by aspirin, which inhibits the first step in coagulation of blood---clumping of platelets.

Vitamins help

Vitamin E slows blood clotting but has fewer side effects than taking aspirin, so it tends to prevent ischemic strokes, the most common type.[11] Vitamin C helps to maintain collagen so it strengthens arteries and makes them more elastic, which tends to prevent high blood pressure and hemorrhagic strokes.[12] So taking vitamin C and E together is beneficial: they both help to keep blood vessels strong and the blood flowing.[11-13] Further, vitamin C can regenerate vitamin E after it completes its antioxidant function.[14,15]

Recommended supplement doses

Since the firing of nerves is what causes muscle contraction, the nervous system needs all the help it can get. Several of the B vitamins are necessary co-factors in the formation of vital neurotransmitters. So I recommend that you work with your own physician and consider taking:

500 mg additional B3 as niacin or niacinamide. Niacinamide does not cause flushing. With niacin, start with 50 mg and GRADUALLY increase over several weeks to 500 mg 2x/day to avoid the skin flush. [9,10]

Many multivitamins contain the B-complex vitamins and some magnesium, zinc, and other essential vitamins and minerals. But you'll want to take additional

Health of nerves is also aided by taking a fish oil supplement rich in omega-3 fatty acids, which makes a more favorable myelin nerve sheath and enhances the transmission of nerve impulses.

Dietary recommendations

Eat a lower-carb diet, which will prevent bone mineral loss from too high sugar intake

Try intermittent fasting to increase growth hormone levels

Do squats and other weight-bearing exercises.

Many elderly people fall because they've broken a brittle femur (the thigh bone), which is one more reason why eating right and taking supplements including vitamin D and magnesium, along with weight-bearing exercise, are so important.

Your balance will be better sometimes than at others. Don't worry about being slow, since the alternative spells trouble. Rather, just give full attention to the task at hand and be thankful for what you can do. You can focus on eating an excellent diet, which means eating colorful vegetables, nuts, unprocessed whole foods, moderate amounts of meat and fish, and adequate doses of supplements of essential nutrients. And you can get adequate, appropriate exercise.

"We get too soon old and too late smart," says the old proverb. Movement with healthy awareness and healthy nutrition can help us get smarter a lot sooner and older maybe a tad later.

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